The management of eosinophilic gastroenteritis

Elemental diet therapy for eosinophilic gastroenteritis and dietary habits

BACKGROUND

Eosinophilic gastrointestinal disorders (EGID) are a group of conditions with increased eosinophilic infiltration in any part of the gastrointestinal tract. Although an allergic reaction to certain foods is considered the main cause of EGID, their detailed pathomechanism has not yet been elucidated, nor have proper management strategies been fully established. Moreover, some patients with intractable EGID are resistant to such therapies as an empirical elimination diet and corticosteroids.

METHODS

We analyzed retrospectively the medical records of four children with intractable eosinophilic gastroenteritis (EGE) managed with elemental diet therapy (EDT) using an amino acid-based formula.

RESULTS

All patients displayed resolution of their symptoms after 2 weeks of EDT. Three patients successfully completed food reintroduction and could return to their normal life. No adverse events related to EDT were recorded.

CONCLUSIONS

Elemental diet therapy appears effective and safe for treating pediatric intractable EGE symptoms. Afterwards, the patient's dietary habits should be considered during carefully monitored food reintroduction. With the relatively small number of published case reports and no randomized trials, more study is needed on EDT for EGE.

Eosinophilic Colitis that Presented with Subepithelial Tumor-like Lesions

Eosinophilic colitis is a rare disease that is characterized by eosinophilic infiltration in the colon wall in symptomatic patients. Thus far, the epidemiology and pathophysiology of eosinophilic colitis have not been well defined, but the hypersensitivity response is likely to play a role in its pathogenesis. The clinical presentation of eosinophilic colitis is usually nonspecific and depends on the layer of the intestinal wall affected by the eosinophilic infiltrate. Eosinophilic colitis is diagnosed generally by exclusion, i.e., after all other causes of eosinophilic infiltration have been excluded. Although there is no consensus over its diagnostic criteria, the laboratory results and radiology and endoscopy findings can provide important diagnostic evidence. This paper reports a case of eosinophilic colitis presenting as subepithelial tumor-like lesions in a 41-year-old man with the chief complaints of abdominal pain and loose stools. The patient had no diseases and no food or drug allergies in his medical history. In general, the endoscopic findings of eosinophilic colitis can vary from a normal mucosa to frank ulcerations. In this case, however, endoscopy revealed subepithelial tumor-like lesions. The colon biopsy showed eosinophilic infiltration in the lamina propria. The patient was treated with steroids, and his symptoms regressed with no signs of relapse.

Disease Course and Treatment Response of Eosinophilic Gastrointestinal Diseases in Children With Liver Transplantation: Long-Term Follow-Up

INTRODUCTION

To describe the clinical and laboratory profile, natural course, treatment outcome, and risk factors of posttransplant esophageal and nonesophageal eosinophilic gastrointestinal disorders (EGIDs).

METHODS

All children (aged <18 years) who underwent liver transplantation, between 2011 and 2019, in a single transplant center with a follow-up period of 1 year or more posttransplant and with a history of posttransplant endoscopic evaluation were included in this study.

RESULTS

During the study period, 89 children met the inclusion criteria. Patients were followed for a median of 8.0 years. A total of 39 (44%) patients were diagnosed with EGID after transplantation. Of these, 29 (33%) had eosinophilic esophagitis (EoE), and 10 (11%) had eosinophilic gastritis, gastroenteritis or enterocolitis. In comparison with the non-EGID group, patients with EGID were younger at transplant (P ≤ 0.0001), transplanted more frequently due to biliary atresia (P ≤ 0.0001), and had higher rates of pretransplant allergy (P = 0.019). In the posttransplant period, they had higher rates of mammalian Target of Rapamycin inhibitor use (P = 0.006), Epstein-Barr virus viremia (P = 0.03), post-transplant lymphoproliferative disease (P = 0.005), and allergen sensitization (P ≤ 0.0001). In regression analysis, young age at transplant, age at diagnosis, pretransplant atopic dermatitis, and post-transplant lymphoproliferative disease were associated with an increased risk of EGID or EoE. Laboratory abnormalities such as anemia (P = 0.007), thrombocytosis (P = 0.012), and hypoalbuminemia (P = 0.031) were more commonly observed in the eosinophilic gastritis, gastroenteritis or enterocolitis group than in the EoE group. Following treatment, most patients had symptomatic resolution at 3 months and histologic resolution at 6 months postdiagnosis. Among the patients who had 5 years of follow-up, none recurred.

DISCUSSION

EGID is a common posttransplant diagnosis, which seems to affect patients who are transplanted earlier and who have pretransplant atopy. Posttransplant EGID is responsive to treatment, but as histologic remission occurs after symptomatic resolution, the decision to perform control endoscopy should be delayed.

Eosinophilic Gastrointestinal Diseases in Children: A Practical Review

Primary eosinophilic gastrointestinal diseases (EGIDs) represent a heterogeneous group of disorders characterized by eosinophilic inflammation in the absence of known causes for eosinophilia, selectively affecting different segments of the gastrointestinal tract. While pediatric eosinophilic esophagitis (EoE) is a well-defined disease with established guidelines, Eosinophilic Gastritis (EoG), Eosinophilic Gastroenteritis (EoGE) and Eosinophilic Colitis (EoC) remain a clinical enigma with evidence based on limited anecdotal case reports. Large cross-sectional studies in the US defined a prevalence of EoG and EoGE ranging from 1,5 to 6,4/100.000 and from 2,7 to 8,3/100.000 subjects respectively, while the prevalence of EoC ranges from 1,7 to 3,5/100.000 subjects. Regarding the pathogenesis, it is hypothesized that EGIDs result from the interplay between genetic predisposition, intestinal dysbiosis and environmental triggers. Clinically, EGIDs might present with different and nonspecific gastrointestinal symptoms depending on the involved intestinal tract and the extension of eosinophilic inflammatory infiltrate. The diagnosis of EGIDs requires: 1. recurrent gastrointestinal symptoms, 2. increased eosinophils for high power field in biopsy specimens, 3. absence of secondary causes of gastrointestinal eosinophilia. No validated guidelines are available on the clinical management of patients with EGIDs. Evidence from case reports and small uncontrolled case series suggests the use of dietary and corticosteroids as the first-line treatments. Considering the clinical follow-up of EGIDs, three different patterns of disease course are identified: single flare, recurring course-disease and chronic course-disease. This review will focus on pediatric EGIDs distal to esophagus, including Eosinophilic Gastritis (EoG), Eosinophilic Gastroenteritis (EoGE) and Eosinophilic Colitis (EoC).

Eosinophilic colitis: A clinical review

Eosinophilic colitis is a rare entity characterized by the presence of a high eosinophilic infiltrate into the colonic wall in symptomatic patients, more often presenting with abdominal pain or diarrhea. These characteristics distinguish eosinophilic colitis from primary colonic eosinophilia, in which patients are asymptomatic. Primary colonic eosinophilia does not need any therapy, while eosinophilic colitis requires a strict treatment, similar to that of the more codified chronic intestinal inflammatory diseases. To date the lack of codified guidelines regarding the diagnostic criteria and the eosinophil threshold values for each colonic segment are the main diagnostic challenge for eosinophilic colitis. In addition, eosinophilic colitis is a diagnosis of exclusion, once all other causes of colonic eosinophilia (food allergens, infections, drugs, etc.) have been excluded. Several treatment options are available for eosinophilic colitis, although the evidence for most of them is limited to case reports and small case series. We examine the epidemiology, etiology, pathophysiology, diagnostic criteria and therapeutic options of eosinophilic colitis reporting recent evidence from the current literature.

Diagnosis and treatment of eosinophilic gastroenteritis in children: A report of 10 cases and literature review

AIM

To investigate the clinical manifestations, diagnosis and treatment of eosinophilic gastroenteritis (EG) in children.

METHODS

We retrospectively analyzed 10 cases of EG diagnosed at the Department of Gastroenterology of Children's Hospital of Chongqing Medical University during the past 4 years (2014-04/2016-04) and reviewed the literature to summarize the characteristics of EG, including clinical manifestations, laboratory, endoscopic, and pathological findings, treatment strategy and prognosis.

RESULTS

Common symptoms were abdominal pain (40%), diarrhea (40%), abdominal distension (20%), vomiting (20%, accompanied by hematemesis), bloody stool (20%), and edema (20%). Nine (90%) had an increased peripheral white blood cell count, 7 (70%) had thrombocytosis, and 9 (90%) had a significantly increased peripheral eosinophil count. On abdominal color Doppler ultrasound, slight liver enlargement was observed in 2 cases, a small amount of ascites in 2 cases, and gastric retention and intestinal distension in 1 case. Gastroscopy was performed in 9 cases and colonoscopy in 1 case. Gastroscopy showed mucosal hyperemia, edema, spotty or patchy erosion and ulcer, and whitish coating in the stomach. Colonoscopy showed mucosal hyperemia, edema, erythema and superficial ulcer. Mucosal pathological examination showed marked mucosal eosinophil infiltration (more than 20 eosinophils per microscopic high-power field) in all cases, and a large number of eosinophils in ascites in 2 cases. Cases were classified as mucosal (n = 8) and subserosal (n = 2). Dietary intervention (amino acid formula) and/or drug therapy (glucocorticoids, leukotriene receptor antagonist, desloratadine, etc.) were administered in the 10 cases. EG-related symptoms were alleviated in 9 cases without recurrence after discontinuation of the therapy. Only 1 case was recurrent after eating fast food.

CONCLUSION

Clinical manifestations of EG are diverse in children. The majority of patients have peripheral eosinophilia. Endoscopy and mucosal biopsy can provide diagnostic clues for EG. Dietary intervention is effective for the treatment of EG in some patients, while corticosteroid treatment remains the best therapy for EG.

Eosinophilic Gastroenteritis: An Underdiagnosed Condition

BACKGROUND

Eosinophilic gastroenteritis (EOGE) is a rare idiopathic disease characterized by eosinophil-predominant inflammation of the stomach and/or intestines. Our aims are to determine the epidemiology, clinical features and outcomes of EOGE cases in a tertiary-care hospital.

METHODS

Retrospective cohort study of patients with gastrointestinal eosinophilic infiltration from 2004 through 2014. All relevant specimens were reviewed by an expert pathologist. Significant eosinophilic infiltrate was defined as >25 eosinophils/HPF in the stomach or small intestine and >50 eosinophils/HPF in the colon.

RESULTS

Three hundred and sixty-one charts were reviewed and 13 EOGE cases were identified, including nine adults and four pediatric cases. The majority (78 %) of adult cases were females. Clinical presentation was variable; most patients (62 %) had abdominal pain, followed by diarrhea (31 %) and nausea/vomiting (31 %). Atopy and food allergies were present in 54 and 38 % of patients, respectively. Weight loss and failure to thrive were present only in pediatric cases (50 vs 0 %; P = .01). Most EOGE cases (69 %) had peripheral eosinophilia, which was more prominent in patients with ascites compared to patients without ascites (37.3 ± 25.4 vs 9.3 ± 5.4 %; P = .01). Among patients who had long-term follow-up; 30 % had spontaneous remission, 60 % responded to steroids and/or restriction diet, and 10 % had refractory disease.

CONCLUSION

EOGE is an underdiagnosed condition. In contrast to eosinophilic esophagitis; the disease might be female-predominant in adults. High index of clinical suspicion is required for diagnosis. Further studies about the long-term outcomes and the efficacy of restriction diet in adult patients are required.

Effect of glucocorticoid on expression of Eotaxin-3 in eosinophilic gastroenteritis

AIM: To detect the expression of eosinophil chemotactic factor-3 (Eotaxin-3) in eosinophilic gastroenteritis (EG) and investigate the effect of glucocorticoid on Eotaxin-3 expression.

METHODS: Forty-eight patients with EG and 24 healthy controls were included. Patients with EG were equally divided into two groups, a placebo group and a prednisone group. Eotaxin-3 expression was measured by enzyme-linked immunosorbent assay in the serum and tissue samples of all subjects.

RESULTS: The expression levels of Eotaxin-3 in serum and tissue were significantly elevated in the EG group compared to normal controls (P < 0.05). Eotaxin-3 in serum and tissue significantly decreased after treatment (P < 0.05), although its change had no significance in the placebo group. A positive correlation was observed between eosinophil (Eos) count and Eotaxin-3 in serum and tissue in the EG group.

CONCLUSION: Eotaxin-3 may be involved in the pathophysiological process of EG. Hormone therapy may inhibit the expression of Eotaxin-3. Serum Eotaxin-3 may be used as a non-invasive index for evaluating the treatment effect in EG.